Reframing Therapy for the 21st Century

Clinical Psychiatry News - Volume 37,
Issue
1, Page 16 (January 2009)

As a psychiatrist who has treated thousands of
patients, I've been struck by the turmoil on Wall Street, and the extent
to which this crisis has forced patients and potential patients to
rearrange their priorities.

People are holding back on buying big-ticket
items and are dropping services and items that they think they can live
without—such as cable TV, eating out, and expensive gifts. And as we
mental health professionals know, many people also are dropping our
services, particularly long-term psychotherapy. Of course, this trend
started long before this recession, but it's likely to continue now.

Why? Traditional psychodynamic psychotherapy
has the reputation of taking a long time and being never ending. It
offers no guarantee that it will help the patient get rid of the
problem. Going way back to those Freudian theories that dramatically,
rightly or wrongly, changed mental health concepts and then adding the
myriad of variations that developed from Freud, the thinking is that if
you don't quit on your own, the therapist will try to keep you there.
Forever.

Just as other industries are coming up with
different models to meet the changing needs of their customers, we need
to change our thinking in terms of our approach to psychotherapeutic
care. As a general rule, we should inform those patients with less
complex disorders that shorter, more focused approaches can help them
solve their problems. Older, traditional, and long-term
psychotherapeutic approaches should be used only in more complex cases.

I believe in short-term psychotherapeutic
approaches that focus on homing in on the problem or problems and are
aimed toward relatively rapid outcome, rather than those archeological
digs that characterize traditional psychotherapy. These traditional
approaches not only have a poor track record (ask the people who were in
it) but also have a huge “dropout rate” (Harv. Ment. Health Lett.
2005;22:3–4).

Over the last few months, I've been
conducting a very unscientific survey about why so many drop out of
psychotherapy. I've been querying people who are in therapy, those who have
discontinued psychotherapeutic care, and therapists—including
psychiatrists.

In addition to viewing therapy as never ending, patients
cited other concerns, such as the tendency to explore issues that seem
irrelevant to why the patient started care, to engage patients in
debates that they feel they cannot win, and to simply listen for 45–50 minutes without adding
any therapeutic guidance. In one particularly poignant observation, one
former long-term patient admitted: “I feel worse than before it
started.”

Another interesting anecdotal point from the
patients/consumers is that most really like their therapists. Perhaps
that explains why it often takes months of soul searching for them to stop scheduling
appointments. Another reason it might take so long is the therapist's
intransigence. Often, when patients try to make the therapy more intermittent or stop
it altogether, the therapist creates an emotional environment that makes
the patient feel guilty or badly—sometimes by suggesting that the
patient is running away from deep-rooted problems.

The therapists with whom I've spoken have
reluctantly conceded that, in their therapeutic work, ending treatment
is not a high priority, and many admit that their patients or clients
do, indeed, drop out before the therapists believe the treatment is
over.

Many therapists truly believe that they are
right in promoting long-term therapy.
They truly consider that they can magically catapult the patient into
wellness. Sadly, these therapists have a difficult time entering the
world of cognitive and behavioral therapies, where problems are
alleviated in focused, pragmatic ways. These therapists are unable to
define for the patient a
reasonable time frame for
the care or the technique to be used.

One person with whom I spoke during my survey
had dropped out after 3 years because the therapist seemed to be going
in a senseless direction. Over those years, the therapist continued to
bring the patient back to some early sexual abuse as a child by a family
member. The therapist's theory was based on the patient's aversions to
certain type of foods. Those aversions had decreased the patient's
socialization—especially on the dating scene.

The patient had no memories of any sexual
abuse but, thanks to the therapist, had started to believe that such
abuse might have occurred. She was unable to steer the therapist away
from the theory that the food aversions that influenced her social life
had originated in some form of abuse. Furthermore, the therapist's
theory was tied up with a myriad of denials and guilt mechanisms that
the therapist suggested—none of which the patient believed.

She really liked the therapist and had
received some benefit. But she needed to stop. She believes the therapy would have continued
“forever” had she let it.

This patient came to therapy to address socialization
issues. Had the therapy been
some form of cognitive or behavior modification, I believe her problems
would have been ameliorated much sooner. Cognitive and behavioral
therapies focus repetitively on intellectual challenges, offering the
patient a greater chance of integrating new perspectives into their
behaviors—both those perceived as normal and maladaptive.

Executive control appears to rest in the
dorsolateral prefrontal cortex (DLPFC). That's where we process and
reprocess information. It seems so clear.

Cognitive and behavioral talk therapies
affect a specific area in the cortex, leading to change. Of course,
explaining to a managed care company that you're having a positive
effect on reprocessing information in a person's DLPFC is not going to
get you paid as quickly as changing medications or dosages.

The Accreditation Council for Graduate Medical Education,
through its residency review committee, has made clear that the
competency requirements in cognitive and brief treatments, for example, short-term
psychotherapy, should be part of psychiatric training and care programs.
Does that mean you learn about it or you learn how to do it? When I ask
people who have completed training, most are able to discuss it. But
rare is the person who is actually able to do cognitive or behavioral
work. Unfortunately, many who still do talk therapy fall back to those
traditional long-term therapies, where they feel comfortable.

The talk therapy
in psychiatric training and care needs an overhaul. If patients are
dropping our services, we are not meeting their needs. It is essential
that we make our doctors as competent in viable contemporary talk
therapies as they are in medication management. We must put to rest
those open-ended, go-nowhere psychotherapies that have so wrongly
dominated not only psychiatry but other disciplines as well while we
move forward in the current economic crisis and in contemporary care. As
psychiatrists, we often set a standard for other disciplines. The
standard needs to be short-term psychotherapy, with a definable
beginning, middle, and end aimed at problem resolution—not trying to
understand the nature of man.

Let me know your thoughts on short-term
psychotherapy, using cognitive and behavior therapies, and moving talk therapy into short-term models. I
will try to pass your thoughts along to my readers.